A new form of smokeless tobacco that looks like candy and has a candy-like flavor poses a threat to children, researchers warned.

Action Points

Explain to interested patients that even relatively small amounts of nicotine in tobacco products can be hazardous for small children to ingest.

A new form of smokeless tobacco that looks like candy and has a candy-like flavor poses a threat to children, researchers warned.

The product -- Camel Orbs, introduced last year by the R.J. Reynolds Tobacco Company -- contains cinnamon or mint flavored dissolvable pellets of tobacco roughly the same size as and in a package similar to Tic Tac mints.

Not only does this pose a risk of ingestion by curious young children, but the quick-absorbing form may also make it more toxic, Hillel R. Alpert, ScM, of the Harvard School of Public Health, and colleagues asserted in the May issue of Pediatrics.

Each pellet, designed as a discreet tobacco substitute for situations when smokers can't light up, contains 1 mg of nicotine, according to the manufacturer.

This amount is sufficient to produce nausea and vomiting in a small child, while 1.0 mg/kg body weight of nicotine would be lethal, the researchers noted in their study of childhood poisonings from tobacco ingestion.

Part of the problem is that the new form of tobacco has a higher pH -- 7.9 compared to less than 6.0 for the average cigarette.

This yields a higher proportion of un-ionized nicotine, which is absorbed more rapidly in the mouth.

Alpert's group's analysis of Orbs tobacco from three test markets where the product was first sold indicated that 42% of the nicotine was un-ionized compared with 28% to 30% for moist snuff and less than 10% for cigarettes.

The FDA is concerned about the potential for enhanced nicotine absorption, according to an editorial in the same issue of Pediatrics.

Marisa L. Cruz, MD, and Lawrence R. Deyton, MD, MSPH, both of the FDA Center for Tobacco Products in Rockville, Md., wrote that the agency is paying close attention to these data because the public health impact of dissolvable tobacco products is one of the first issues on which it is seeking input under new powers granted by the Tobacco Control Act.

Its first regulatory move was to ban the manufacture and sale of all cigarettes with characterizing fruit, candy, and clove flavors last fall, the editorialists noted. (See Flavored Cigarette Ban Takes Effect)

The new dissolvable class of products isn't limited to Camel Orbs but includes other products, including thin strips, tablets, and sticks that resemble toothpicks -- all a reaction to laws that restrict indoor smoking, they said.

One case of Orbs ingestion by a 3-year-old has already been reported to the Oregon Poison Control Center.

A spokesperson for R.J. Reynolds Tobacco Company said it was not aware of this case or any other pediatric adverse events due to Orbs ingestion prior to the publication, but that it has provided information on its product to poison control centers across the country.

"One accidental ingestion death is one too many," he said in an interview but cautioned that this should be put in the context of substantially higher numbers of accidental poisoning deaths from dietary supplements, cosmetics, and even nicotine replacement products.

Although Camel Orbs contain flavorings similar to candy, the product still tastes like tobacco, the spokesperson emphasized.

He noted that the packaging requires simultaneous use of both hands to open, meets government standards for child resistance, and has been called difficult to open even by adults.

The company placed the responsibility for keeping kids away from these products on adult users.

"First and foremost, adult tobacco consumers should be diligent in ensuring kids don't have access," the spokesperson told MedPage Today.

Nevertheless, "adults might take multiple pellets out of the container for convenience and unknowingly leave them where infants or children might find and ingest them," Alpert's group warned.

Smokeless forms of tobacco ranked second only to cigarettes as the most common source of tobacco ingestion among young children, according to their report.

They analyzed 13,705 tobacco product ingestion cases by children under 6 years of age (the age range responsible for 90% of such accidental cases in the population) reported to 61 regional poison control centers from 2006 through 2008.

"Infants are susceptible to accidental tobacco ingestion because of a natural curiosity and a tendency for oral exploration," they wrote in Pediatrics.

Indeed, more than 70% of the ingestions in their study were by infants under 1 year old.

Smokeless tobacco accounted for a higher proportion of tobacco ingestions with each year of age from the first to 5 years (OR 1.94, 95% confidence interval 1.86 to 2.03).

While the report focused on young children, the new pellet form of tobacco poses a risk to older children as well, the researchers warned.

"The discreet form of Orbs might make ingestion of nicotine, a highly addictive drug, easy and attractive for adolescents," they wrote in the journal article, recommending that federal and other public health authorities look into the potential to cause pediatric poisonings and addiction.

The FDA is already doing so, according to Cruz and Deyton.

The agency has requested information from manufacturers and will be starting a public docket to seek "research around the impact of marketing for dissolvable tobacco products on young people, how adolescents and young adults perceive such products, and whether dissolvable tobacco products may lead to initiation or persistence of tobacco use in this population," they wrote in the editorial.

The researchers reported no conflicts of interest. Cruz and Deyton reported no conflicts of interest.

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